What’s the future of drug policy? An interview with America’s ‘Drug Czar’

August 29, 2013
R. Gil Kerlikowske, director of the White House Office of National Drug Control Policy, delivers opening remarks commemorating the first annual National Above The Influence Day during National Substance Abuse Prevention Month at the Newseum in Washington, D.C. on October 18. (Bryan Whitson / Bryan Whitson)
R. Gil Kerlikowske delivers opening remarks commemorating the first annual National Above The Influence Day at the Newseum in Washington, D.C., on Oct. 18. (Bryan Whitson for The Washington Post)

Gil Kerlikowske is director of the White House Office of National Drug Control Policy (in more common parlance, America’s “Drug Czar.”) He was recently nominated to be commissioner of Customs and Border Protection. So this is an especially good moment to take stock of U.S. drug policies on several fronts. I caught up with  Kerlikowske by e-mail. Below is our lightly edited exchange.

Harold Pollack: What would you say has been the Obama administration’s most important accomplishment in substance abuse policy since you took office? Conversely, what would you describe as your greatest disappointment in this contentious area?

Gil Kerlikowske: There are many areas in which we’ve made great progress. Our comprehensive approach to the prescription drug abuse epidemic is resulting in the first decline in the number of Americans abusing prescription drugs in a decade. Cocaine and meth use are also plummeting. The implementation of the Affordable Care Act is also important, because it will require a public health approach to substance use disorders in America by mandating insurance companies to treat addiction the same way they would any other disease.

We’ve worked hard to change the dialogue when it comes to evidence-based criminal justice reform. Expanding programs like drug courts that divert nonviolent offenders into treatment instead of prison is one example. By signing the Fair Sentencing Act into law, President Obama finally reduced the longstanding disparity between crack and powder cocaine sentencing and eliminated the first mandatory minimum drug law in 40 years. Building on that record, Attorney General [Eric] Holder’s recent announcement in how the Department of Justice addresses mandatory minimums for nonviolent offenders and compassionate release is also historic, and I’m proud to have played a role in tackling that issue.

But there’s much more work to be done. Today, only 1 in 10 Americans who need treatment ever receive it, and the number of people dying from drug-induced deaths remains far too high. We’ve got to do a better job of reframing drug policy as a public health issue and not just a criminal justice issue, and in so doing continue to let science and evidence be our guide.

HP: I was surprised that you didn’t mention one disappointment, which is the limited budget. The Obama administration has reframed the rhetoric of drug control policy. Yet the dollars, particularly in the area of prevention, haven’t really been there to implement ambitious new efforts. Budgets are particularly tight under the sequester, but this has been a chronic problem. Where are we under-investing in drug policy?

GK: First – It’s important to note that despite the conventional wisdom in this area, the federal government actually spends more on prevention and treatment than it does on domestic U.S. drug law enforcement and incarceration. While that breakdown does not include interdiction or support for international programs, the fact still remains that we spend more in one year on demand reduction efforts than we have, for example, on the entirety of Plan Colombia over eight years or in total counternarcotics aid for Mexico’s Merida initiative.

Additionally, the president’s most recent budget includes a requested increase of $1.4 billion for treatment for FY 2014 —  the largest such percentage increase for treatment in at least two decades. Our support for prevention remains strong and we’re very engaged with Congress to ensure they continue to support important prevention programs like our Drug Free Communities program, which supports hundreds of community coalitions at the local level. It is true that interdiction is largely a cost born by the federal government and thus more expensive, accounting for a large percentage of federal drug control spending. However, the work of the Coast Guard and Border Patrol are vital not just to public safety but also to public health, and they will always remain a piece of our comprehensive strategy.

Health reform

HP: In a few months, health insurance marketplaces will be open for business in 50 states. Medicaid will expand in about half the states, as well. Mental health parity and expanded substance abuse coverage are important parts of health reform. Are states ready to go with this? Are substance abuse providers ready? How is the implementation process going in this area?

GK:  We’re working very closely with the Department of Health and Human Services and stakeholders to ensure treatment providers are ready for ACA implementation. This has been a long process. Since the ACA was passed, we’ve been providing guidance, technical assistance, and are in close touch with the field to ensure the field is ready. Providing treatment for substance use disorders is important and will also save costs moving into the future.

HP: Millions of low-income people are both uninsured and experience drug or alcohol disorders. Many live in states that have opted out of the Affordable Care Act’s Medicaid expansion. What are states and the federal government doing to meet the needs of this population in non-expansion states?

GK: If states don’t expand their Medicaid programs, a lot of low-income working families and some of our country’s most vulnerable would be left no source of affordable health coverage at all – including for substance use disorders. We can’t let that happen. There’s money left on the table and lives left at risk. And no one’s health should depend on their Zip code.

Sentencing reform

HP: Attorney General Holder recently spoke of the need for less punitive sentencing of nonviolent offenders on the supply-side of the drug market. He directed U.S. attorneys to use their discretion to advance this goal. Of course, the great majority of drug offenders are outside the federal system. What can states and localities do to focus more closely on more violent or more important drug-sellers? Should ONDCP take this issue on as one of its core missions?

GK: Absolutely, and we are, as the attorney general mentioned in his speech. In fact, more than 17 states and 18 counties are in various stages of significant criminal justice reform. As you can imagine, change like this takes time, but states and localities are moving in the right direction by supporting alternatives for low-level, nonviolent drug offenders while reinvesting in smarter supervision strategies, treatment, and other services. That’s what real drug policy reform looks like. And we’re seeing historic movement in this area. For the first time in 40 years, we’re seeing a decline in the number of people in state prisons.

It’s worth noting that these reforms have broad bipartisan support. We’re seeing progress in both red and blue states – from Texas, Georgia and Kentucky to Ohio, Pennsylvania and Connecticut.

International matters

HP: Tens of thousands of people have died in Mexico in recent years as drug-selling organizations battle each other and the Mexican government. What can the U.S. government do to lessen this violence, and more fundamentally to induce less violent business models among the organizations that smuggle drugs into this country?

GK: We’re determined to meet our responsibilities to reduce the demand for illegal drugs. The good news is that since 2006, there has been a significant decline in cocaine use in the U.S. of over 40 percent and meth use has been cut by a third. Moreover, our border with Mexico is more secure than in history due to the unprecedented resources this administration has placed there.

Every country has a drug consumption problem and our balanced approach is, in part, what our friends in this hemisphere have requested: that we focus on reducing our own consumption of drugs. We also have been sharing our experience with drug courts; diverting nonviolent drug users into court-supervised drug treatment programs. We have invited our Mexican partners to visit and see the Drug Courts in action and to return to Mexico to shape effective Drug Courts to the needs of Mexico.

It’s worth noting that the violence in Mexico is perpetrated by organizations that are not just “drug-trafficking organizations,” but rather Transnational Criminal Organizations who engage in a diverse range of illegal activities. They not only move drugs to the United States but also fuel the drug market in Mexico and in many instances pay for services (with drugs) in kind. Alejandro Junco, a distinguished Mexican journalist and owner of Grupo Reforma, made another compelling point: Once the dominating cartel establishes territorial control, it turns to the most profitable part of its operation — selling protection to local businesses. Kidnappings, extortion, piracy, contraband, prostitution — cartels will turn to almost anything illegal that makes money. So, the suggestion that drug legalization would cause transnational organized crime to dissolve is just a distraction.

HP: The last time you and I spoke, I moderated a conversation in Chicago with your Russian counterpart, Viktor Ivanov. Ivanov wanted the United States to pursue mass crop eradication in Afghanistan. You responded that Afghanistan is a sovereign country which does not wish us to pursue such policies. Afghanistan is a dominant supplier in the opium market. How is the United States government approaching that problem?

GK: Supporting the government of Afghanistan's counternarcotics efforts remains a priority for the United States. It is an integral part of our stability and security strategy for the region. We support Afghan-led eradication as a law enforcement tool to reduce and deter subsequent year poppy cultivation. Afghan-led eradication has been especially effective at the local level where local leaders and communities are involved in the eradication process. When eradication is implemented as a continuum of supply reduction activities and coupled with alternative development, it has proven effective in deterring cultivation and transitioning farmers away from poppy.

At the same time, we recognize that eradication is not the only solution to the drug problem in Afghanistan; it is one tool in the supply reduction toolkit that can be leveraged to reduce and prevent cultivation. In addition to eradication, we also support other law enforcement measures, including interdiction, judicial reform and capacity building, demand reduction efforts and treatment centers, public information campaigns and alternative development.

Marijuana

HP: California and Massachusetts are among the states that decriminalized marijuana during the Obama administration. Prior administrations campaigned actively against states doing this. The current administration did not. Why not?

GK: As you noted previously, the vast majority of drug enforcement happens at the state and local level and not the federal level. Many states are looking at various alternatives to incarceration. With regard to the federal position, the administration’s position has been clear and consistent: While the prosecution of drug traffickers remains an important priority, targeting individual marijuana users is not the best allocation of federal law enforcement resources.

HP: The president has announced his desire to find some accommodation between the Controlled Substances Act and the new laws in Colorado and Washington. How does the administration plan to do this?

GK: This is a question for the Department of Justice, which is currently reviewing this issue.

Generally speaking, however, both President Obama and I have been clear and consistent in our opposition to legalization. This stems from the fact that legalization runs counter to a public health approach to drug policy.

HP: You say that “legalization runs counter to a public health approach to drug policy.” Most experts I know tend to avoid that term. They speak of more granular changes, typically on the demand rather than the supply side of illicit markets. For example, many favor removal of criminal penalties for possession of relatively small amounts of marijuana for personal use but would not allow a fully-legitimate market that includes industrial-scale production, national distribution and marketing as we see for alcohol or cigarettes. As our society gropes for some compromise on the marijuana issue, is there some less extreme way to pose things that moves away from a supposed choice between drug warriors and legalizers in this debate?

GK: When we released our drug policy reform plan we made clear that we need to move to a 21st century approach to this challenge instead, one that offers evidence-based alternatives based on realistic goals. There are a whole host of alternatives to incarceration we are actively supporting that move away from those extremes. Drug courts, which are referring over 120,000 nonviolent drug offenders into treatment instead of prison a year is a good example. The Drug Market Intervention model is another, which separates low-level offenders from higher-level offenders and connects them to services instead, in so doing providing low-level offenders with a second chance instead of burdening them with a criminal record that follows them for the rest of their life.

Is the culture war over in drug policy?

HP: In the prior administration, ONDCP officials condemned organizations that distributed naloxone to prevent opioid overdoses. The current administration has given such organizations awards. What do you think accounts for this change?

GK: When President Obama first took office he made it very clear to all of us that when it comes to policymaking decisions – particularly those that impact public health and safety – science and evidence should be our guide, not ideology or dogma. We know that prevention and treatment remain the most cost effective and humane ways to reduce drug use and its consequences in America, but we have to also acknowledge that there are other tools we can also use that save lives and help guide people into treatment.

One of those tools is naloxone – a lifesaving drug that has been proven to reverse overdose. One police department in Quincy Massachusetts has already reversed over 175 overdoses since 2010 using Naloxone. Given the fact that drug-induced deaths are now the second leading cause of injury death in the U.S. we have a responsibility to employ every tool we have in our work to save lives.

HP: Listening to that conversation in Chicago, I was also struck by the contrast between you and your Russian counterpart. Ivanov opposed syringe exchange and methadone maintenance. You responded that both approaches were helpful in preventing HIV and in reducing drug use. That’s not the way your predecessors spoke 20 years ago, when drug policy was a raging front in the culture wars.

I’m also struck that many conservatives and Republicans who might once have attacked (say) Holder were conspicuously quiet this time. Libertarians such as Rand Paul have spoken out against mandatory minimum sentences. Conservatives such as Grover Norquist, Newt Gingrich and even William Bennett associate with groups like Right on Crime that have also supported more moderate sentencing policies. President George W. Bush was not an angry politician on this front, either.

This long windup leads me to a simple question: Is the culture war over in drug policy?

GK: We have worked hard over these last several years to do just that. Science provides all of us with a clear path on how to pursue real drug policy reform. Research demonstrates that addiction is a disease of the brain that can be prevented, treated and recovered from – it is not a moral failure on the part of the individual. It hinges on a complex set of genetic, environmental  and behavioral factors. It is also a unique disease in that too many people who suffer from it do not seek help on their own, and eventually end up coming into contact with the criminal justice system.

This is not my opinion or a political statement – it’s a fact – and provides the foundation for which everyone should be working from when it comes to drug policy. It also serves as the basis for the administration’s 21st century approach to drug policy reform, which rejects both the extremes of a law-enforcement-centric “war on drugs” on the one hand and drug legalization on the other – both of which run counter to this science-based approach.

The president has outlined his vision of an America built to last — where an educated, skilled workforce has the knowledge, energy and expertise to compete in the global marketplace. Yet  for far too many Americans, that vision is limited by drug use, which not only limits the potential of the individual but jeopardizes families, communities and neighborhoods.

The good news is that we know we are not powerless against this challenge. Today, there are 23 million Americans in recovery from a substance use disorder. These folks are our family members, they are out co-workers  and they are our neighbors. They’re also living proof that by pursuing smart approaches, we can make America healthier and safer.

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